Society of Nuclear Medicine Procedure Guideline for 99mTc-Exametazime (HMPAO)-Labeled Leukocyte Scintigraphy for Suspected Infection/Inflammation

Version 3.0, approved June 2, 2004

Authors: Christopher J. Palestro, MD (Long Island Jewish Medical Center, New Hyde Park, NY); Manuel L. Brown, MD (Henry Ford Hospital, Detroit, MI); Lee A. Forstrom, MD, PhD (Mayo Clinic, Rochester, MN); Bennett S. Greenspan, MD (Harry S. Truman VA Medical Center, Columbia, MO); John G. McAfee, MD (George Washington Hospital, Washington, DC); Henry D. Royal, MD (Mallinckrodt Institute of Radiology, St. Louis, MO); Donald S. Schauwecker, PhD, MD (Richard L. Roudebush VA Medical Center, Indianapolis, IN); James E. Seabold, MD (Carl T. Hayden VA Medical Center, Phoenix, AZ); and Alberto Signore, MD (University La Sapienza, Rome, Italy).

I.

Purpose
The purpose of this guideline is to assist nuclear medicine practitioners in recommending, performing, interpreting, and reporting the results of 99mTcexametazime (HMPAO) labeled leukocyte (99mTcleukocyte) scintigraphy.

II. Background Information and Definitions

Tc-leukocyte scintigraphy consists of regional, whole-body, planar, and SPECT scintigrams obtained after intravenous injection of 99mTc-labeled leukocytes.
99m

III. Examples of Clinical or Research Applications for 99mTc-Leukocyte Scintigraphy

A. To detect suspected sites of acute inflammation/infection in the febrile patient with or without localizing signs or symptoms.

1. To detect site(s) of inflammation as a cause of abdominal pain. 2. To localize site(s) of infection in patients with granulocytosis and/or positive blood cultures. B. To detect and determine the extent of inflammatory or ischemic bowel disease. This technique may be more sensitive than 111In-leukocyte scintigraphy for detection of disease, particularly involving the small bowel. 111In-leukocytes are preferred for quantitative assessment. C. To detect and follow up musculoskeletal infection, such as septic arthritis and osteomyelitis. 1. May be more sensitive for detection of acute than chronic osteomyelitis. 2. Combined 111In-white blood cell (WBC)/ 99m Tc-diphosphonate bone and/or 111InWBC/99mTc-sulfur colloid marrow scans are preferred in difficult cases of osteomyelitis at sites with existing bone alteration and/or adjacent soft-tissue infection.

The Society of Nuclear Medicine (SNM) has written and approved these guidelines as an educational tool designed to promote the costeffective use of high-quality nuclear medicine procedures or in the conduct of research and to assist practitioners in providing appropriate care for patients. The guidelines should not be deemed inclusive of all proper procedures nor exclusive of other procedures reasonably directed to obtaining the same results. They are neither inflexible rules nor requirements of practice and are not intended nor should they be used to establish a legal standard of care. For these reasons, SNM cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment about the propriety of any specific procedure or course of action must be made by the physician when considering the circumstances presented. Thus, an approach that differs from the guidelines is not necessarily below the standard of care. A conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in his or her reasonable judgment, such course of action is indicated by the condition of the patient, limitations on available resources, or advances in knowledge or technology subsequent to publication of the guidelines. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective. Advances in medicine occur at a rapid rate. The date of a guideline should always be considered in determining its current applicability.

99m

Tc-EXAMETAZIME (HMPAO)-LABELED LEUKOCYTE SCINTIGRAPHY FOR SUSPECTED INFECTION/INFLAMMATION

IV. Procedure
A. Patient Preparation In children, a 24 h fast may help reduce hepatobiliary excretion and bowel transit. In adults, fasting may have less effect. B. Information Pertinent to Performing the Procedure 1. Coordination of this procedure with the referring physician is essential. Clinical history and the results of prior tests are essential, including: any history of surgery or trauma, the presence and location of surgical drains, skin or soft-tissue infection and intravenous administration sites and the presence of nasogastric and/or ostomy (tracheostomy, colostomy, feeding gastrostomy, etc.) tubes. Bone radiographs, bone scans, and other imaging studies may be very helpful in assessing the cause of abnormal 99mTc-leukocyte localization in bone. 2. 99mTc-labeled leukocyte scintigraphy, when compared with 111In-labeled leukocyte scintigraphy, has the advantages of earlier and shorter imaging times, lower absorbed radiation dose, and a smaller blood sample for labeling leukocytes. 3. 111In-leukocyte scintigraphy is preferred in some patients with suspected sites of inflammation or infection in the abdomen/pelvis, because, unlike 99mTc-leukocytes, there is normally no excretion into gastrointestinal or urinary tracts. 4. 111In-leukocyte scintigraphy may be preferred in patients with suspected sites of infection in the chest who might have prolonged lung blood pool activity as a result of congestive heart failure, septic shock, renal failure, etc. (See the Society of Nuclear Medicine Procedure Guideline for 111In-Leukocyte Scintigraphy for Suspected Infection/Inflammation.) 5. 67 Ga is preferred for evaluation and follow-up of active lymphocytic or granulomatous inflammatory processes, such as tuberculosis or sarcoidosis, and especially in the immunocompromised patient for detecting opportunistic infections. C. Precautions Procedures and quality assurance measures for correct identification of patients and handling blood products are essential. The labeled leukocytes should be re-injected as soon as possible and preferably within 12 h after labeling. Use of central intravenous lines requires strict sterile technique.

D. Radiopharmaceutical (For additional details on labeling see Society of Nuclear Medicine Procedure Guideline for Use of Radiopharmaceuticals.) 1. Leukocytes are obtained from 4060 mL of venous blood in adults. Circulating granulocyte counts should be a minimum of 2 106 cells/mL. Whole blood is normally obtained by direct venipuncture and mixed immediately with ACD anticoagulant. 2. In children, the amount of blood depends on the patient size and circulating leukocyte count. The minimum volume of blood obtained is about 1015 mL. 3. Only the unstabilized form of exametazime (HMPAO) should be used for labeling. (Do not use methylene blue in this procedure.) For details of cell labeling, see articles in bibliography. 4. For adults, the usual administered activity is 185370 MBq (510 mCi) of 99mTc-HMPAOlabeled WBC. 5. For children, the usual administered activity is 3.77.4 MBq/kg (0.10.2 mCi/kg). The usual minimum pediatric administered activity is 1837 MBq (0.51.0 mCi). The maximum administered activity in a child should not exceed the maximum administered activity for an adult. 6. Exametazime (HMPAO) is a lipophilic complex which penetrates the leukocyte cell membrane and is retained within the cell. 7. The spleen, bladder, and large bowel receive the largest radiation absorbed dose. 8. Leukocyte migration, chemotaxis, phagocytosis, intracellular killing, and adhesive and superoxide generation have been shown to remain normal after labeling with 99mTcHMPAO. E. Image Acquisition 1. A large-field-of-view gamma camera with a low-energy high-resolution collimator is usually preferred. If count rates are low on the 1624-h delayed images, a low-energy allpurpose collimator can be used. The pulse height analyzer is centered at 140 keV using a 15%20% window. 2. Early imaging of the pelvis and abdomen is essential (bowel activity is seen in 20%30% of children by 1 h and 2%6% of adults by 3 4 h after injection). See normal findings in section IV.H.1.b. a. Regional images are obtained for at least 800,000 counts/large field of view or 5 10 min/view.

SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES

Radiation Dosimetry: Adults1

Radiopharmaceuticals Administered activity MBq (mCi)
Tc-exametazime (HMPAO) leukocytes 1
1

Organ receiving the largest radiation dose mGy/MBq (rad/mCi)

0.15 Spleen (0.56)

Effective dose equivalent mSv/MBq (rem/mCi)

0.017 (0.063)

99m

185370 iv (510)

International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals. ICRP Publication 53. London, UK: ICRP; 1988:232.

Radiation Dosimetry: Children (5 Years Old)

Radiopharmaceuticals Administered activity MBq/kg (mCi/kg) Organ receiving the largest radiation dose mGy/MBq (rad/mCi)
0.48 Spleen (1.8)

Effective dose equivalent mSv/MBq (rem/mCi)

0.054 (0.20)

Tc-exametazime (HMPAO) leukocytes 1

1

99m

3.77.4 iv (0.10.2)

International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals. ICRP Publication 53. London, UK: ICRP; 1988:232.

b. Whole-body images should include the anterior and posterior head, chest, abdomen, pelvis, and extremities when clinically indicated. A limited study to evaluate a specific region of the body is acceptable in select cases. 3. Images of the limbs should be acquired for 10 min/view at 48 h and at least 15 min/view at 1624 h (particularly for osteomyelitis). 4. SPECT images of the chest, abdomen/pelvis, or spine may be helpful. F. Interventions None. G. Processing See the Society of Nuclear Medicine Procedure Guideline for General Imaging. H. Interpretation Criteria Accurate interpretation of labeled leukocyte scintigraphy requires knowledge of the normal and abnormal variants of leukocyte localization. 1. Normal Findings a. The blood clearance half-life of 99mTcleukocytes is about 4 h, and delayed im-

ages (longer than 4 h) may be preferred for detection of vascular graft or dialysis shunt infection. 111In-leukocytes may be preferred for detection of vascular graft or dialysis shunt infection, because blood pool activity is much lower relative to sites of abnormal localization (especially on 1824-h delayed images). b. Bowel activity secondary to secretion of 99m Tc complexes is seen in 20%30% of children by 1 h but is usually not seen in adults before 4 h. In adults, physiologic bowel activity is usually faint if seen at 4 h and is usually seen in the terminal ileum or right colon, increasing over time. c. Renal and bladder activity is seen by 15 30 min in all patients with normal renal function. The patient should try to empty his/her bladder before pelvic imaging. d. Uniform physiologic gallbladder activity can be seen in 4% of patients by 24-h and up to 10% of patients by 24 h. A curvilin-

99m

Tc-EXAMETAZIME (HMPAO)-LABELED LEUKOCYTE SCINTIGRAPHY FOR SUSPECTED INFECTION/INFLAMMATION

ear pattern at the margin is suspicious for inflammation of the gallbladder wall.

Image Acquisition
Diagnosis Abdominal abscess Inflammatory or ischemic bowel disease Chestpulmonary infection Osteomyelitis

Early Imaging
0.51 h for adults 2040 min for children 0.5 1 h for adults 2040 min for children Physiologic lung activity may interfere May not have sufficient localization

Delayed Imaging
Sequential to 4 h

1624-h imaging
Rarely, if early images are negative (requires longer imaging times) Usually not indicated, because physiologic bowel activity is present If early images are negative (requires longer imaging times) If early images are negative or equivocal (requires longer imaging times)

Sequential up to 4 h; physiologic bowel activity may interfere on later images 48 h 48 h

e. The spleen, liver, bone marrow, kidneys, bowel, bladder, and major blood vessels will normally be visualized. 2. Abnormal Findings a. Abnormal bowel localization may be seen by 1530 min and usually increases in intensity over the next 23 h. i. The degree and extent of bowel disease is usually demonstrated by 12 h. ii. Shifting patterns of bowel activity on later images usually indicates distal transit of labeled granulocytes or, at times, bleeding within the bowel lumen. b. Lung activity usually clears by 4 h, unless there is pulmonary edema, diffuse inflammatory lung disease, atelectasis, renal failure, sepsis, or adult respiratory distress syndrome. c. Focal abdominal activity outside the liver and bowel is likely to indicate infection/inflammation but can vary greatly in intensity depending on the degree of inflammation. Caution should be used in interpretation of a focal site of abnormal localization, as indicating a drainable abscess and correlation with other imaging modalities is recommended. d. Infection involving the spine may present as areas of increased or decreased activity compared with normal bone marrow localization. Photopenic or cold defects may indicate osteomyelitis, but other causes, such as compression fracture, neoplasm, postirradiation changes, or postsurgical or

anatomic deformities, should also be considered. I. Reporting The report should include the following information: 1. Indication for the study 2. Procedure a. Dose of radiopharmaceutical b. Time(s) of acquisition postinjection c. Type of images (whole body, regional, SPECT) 3. Findings a. Site(s) of abnormal localization b. Degree of localization compared with liver, bone, or bone marrow uptake and whether it increased over time if delayed images were obtained 4. Study limitations or confounding factors 5. Impression (e.g. positive, negative, indeterminate) a. The clinical significance of the findings b. If appropriate, differential clinical diagnoses J. Quality Control 1. The labeling efficiency of 99mTc-labeled leukocytes may be determined by recentrifugation (approximately 150 g for 8 min) of the labeled leukocytes. The supernatant is poured into a separate counting tube, and the leukocyte pellet is resuspended in 5 mL of cell-free plasma. Each tube is then counted in a dose calibrator. Labeling efficiency = resuspended Tc-leukocyte activity / [(resuspended Tcleukocyte activity) + (supernatant activity)] 2. Leukocyte clumping is checked by looking at a drop of 99mTc-labeled leukocyte suspension

SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES

placed on a hemocytometer slide and viewed under a microscope under low and medium power. There should be no clumping. The leukocyte suspension can be filtered with a 16-gauge filter needle to remove leukocyte clumps. 3. A rough estimate of the number of cells labeled can be made by visual examination of a representative sample on a hemocytometer slide. The average number of cells per 50micron (small) square is then determined. No. of cells/cm3 (mL) = average number of cells/ small square (2 106). This step is optional. K. Sources of Error 1. Note that the normal biodistribution of 99mTcleukocytes differs from that of 111Inleukocytes. In adults, a changing pattern of bowel activity prior to 4 h is likely from intraluminal transit of labeled cells secondary to inflammatory bowel disease or bleeding, or may indicate a fistula from an abscess. In children, progressive physiologic bowel activity can be present by 1 h. Delayed imaging alone is often misleading in inflammatory bowel disease. Bone marrow expansion or hyperplasia can alter the normal marrow patterns. (See the Society of Nuclear Medicine Procedure Guideline for 111In-Leukocyte Scintigraphy for Suspected Infection/Inflammation, section IV.J. for other sources of errors.) 2. False-negative results occur as a result of rapid bowel clearance of labeled leukocytes from inflamed bowel, particularly in the small bowel. Bladder activity may mask a pelvic site of infection (voiding or, when necessary, catheterization is suggested before pelvic imaging). Normal renal activity can make it difficult to detect pyelonephritis and/or a small renal abscess. Chronic walled-off abscesses or low-grade infections, particularly in bone, have less 99mTc-granulocyte accumulation and are more likely not to be visualized. Residual diffuse lung activity, particularly in patients with heart or renal failure, may obscure focal lung infections even as late as 46 h after injection. 3. False-positive results can occur from rapid small bowel transit of hepatobiliary secretion and focal accumulation of activity in the cecum, particularly if imaging is done after 1 h in children or 4 h in adults. Active gastrointestinal bleeding or swallowed cells can be mistaken for an inflammatory bowel process. Focal collections of inflamed peritoneal fluid or sites of focal bowel inflammation can be mistaken for abscess. Hematomas and inflammation around neoplasms such as lym-

phomas may also mimic an abscess. Noninfected vascular grafts and/or shunts can show increased localization because of bleeding or noninfected reparative process.

V. Issues Requiring Further Clarification

A. Relative efficacies of 111In-labeled leukocytes, 99m Tc-labeled leukocytes and 99mTc-fanolesomab in different clinical conditions B. Radiation effects using 99mTc doses greater than 20 mCi on granulocyte viability during 99mTcHMPAO labeling procedure

VI. Concise Bibliography

A. Arndt JW, Veer A, Blok D, et al. Prospective comparative study of technetium-99m-WBCs and indium-111-granulocytes for the examination of patients with inflammatory bowel disease. J Nucl Med. 1993;34:10521057. Clinical comparison study. B. Brown ML, Hung JC, Vetter RJ, et al. The radiation dosimetry and normal value study of 99mTcHMPAO-labeled leukocytes. Invest Radiol. 1994;29:443447. C. Datz, FL. The current status of radionuclide infection imaging. In: Freeman LM (ed). Nuclear Medicine Annual 1993. New York, NY: Raven Press, Ltd; 1993:4776. General reference. D. Dewanjee MK. The chemistry of Tc-99m labeled radiopharmaceuticals. Semin Nucl Med.1990;20: 57. Labeling technique. E. Giaffer MH, et al. Value of technetium-99m HMPAO-labeled leucocyte scintigraphy as an initial screening test in patients suspected of having inflammatory bowel disease. Eur J Gastrol Hepatol. 1996;8:11951200. F. Kipper SL. Radiolabeled leukocyte imaging of the abdomen. In: Freeman LM (ed). Nuclear Medicine Annual 1995. New York, NY: Raven Press, Ltd; 1995:81128. General overview. G. Mansfield JC, Giaffer MH, Tindale WB, et al. Quantitative assessment of overall inflammatory bowel disease activity using labeled leucocytes: a direct comparison between indium-111 and technetium-99m HMPAO methods. Gut. 1995;37: 679683. H. McAfee JG. What is the best method for imaging focal infections? J Nucl Med. 1990;31:413416. Overview of labeling techniques. I. Pavola PC, Carremon FL, Thorson LM, et al. Optimal storage temperatures and times for indium111-oxine labeled leukocytes. J Nucl Med Technol. 1995;23:126.

99m

Tc-EXAMETAZIME (HMPAO)-LABELED LEUKOCYTE SCINTIGRAPHY FOR SUSPECTED INFECTION/INFLAMMATION

J. Peters AM. The utility of Tc-99m HMPAOleukocytes for imaging infection. Semin Nucl Med. 1994;24:110127. Clinical overview. K. Roca M, Martin-Comin J, Becker W, et al. A consensus protocol for white blood cell labelling with technetium-99m hexamethylpropylene amine oxime. Eur J Nucl Med.. 1998;25:797799. Standardized labeling technique.